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A Novel Frameless Laser Stereotaxis System for Neurosurgical Interventions: Will do

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A Novel Frameless Laser Stereotaxis System for Neurosurgical Interventions

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A Novel Frameless Laser Stereotaxis System for Neurosurgical Interventions
Dan Tang1, Jun liu2, Chunwen Xiao3, Dujie Xie4, Xiaohong Fu5, Shenghua Cui6,BoHe7, Mingchu Li8, Lingyun Zhang3-OBJECTIVE:

The aim of the article is to introduce a novel
laser-based frameless stereotactic device that can locate
intracranial lesions quickly and with computed tomograph
(CT)/magnetic resonance imaging (MRI) films. Preliminary
experiences of application in 416 cases are also
summarized.-METHODS: From August in 2020 to October in 2022, a
total of 416 cases of new minimalist laser stereotactic
surgery have been performed on 415 patients. Of the 415
patients, 377 had intracranial hematomas, while the
remaining cases were brain tumors or brain abscesses.
Postoperative CT was used to evaluate the accuracy of
catheterization of 405 patients according to the MISTIE
study. The duration time of locating was recorded.
Rebleeding refers to the definition: Compared with preop
erative CT, the relative volume of postoperative hematoma
increases by >33% or absolute volume increase >12.5 mL.-RESULTS: According to postoperative CT, the accuracy
of 405 stereotactic catheterization cases was good in 346
cases (85.4%) and suboptimal in 59 cases (14.6%), with no
poor results. Postoperative rebleeding occurred in 4
spontaneous cerebral hemorrhage cases and 1 brain biopsy
case. The average localization time of supratentorial le
sions was 13.2 minutes in the supine position, 21.5 minutes
in the lateral position, and 27.6 minutes in the prone
position.-CONCLUSIONS: The new laser-based frameless stereo
tactic device is simple in principle and convenient in
positioning operation of brain hematoma and abscess
puncture, brain biopsy and tumor surgery, and appropriate
to the precision requirements in most craniocerebral
surgery.
INTRODUCTION
Highacquisition and maintenance costs have hindered
many neurosurgical centers in China and other low- and
middle-income countries from providing stereotactic
assisted neurosurgical care.1 In China, more than 1 million
patients suffer from hypertensive intracerebral hemorrhage per
year, with more than 100,000 among them requiring minimal
invasive surgeries.2 The freehand technique for insertion of a
drainage tube based on experience is often inefficiently precise.
Hence, hospitals and doctors are denied a low-cost and time
efficient stereotactic platform, especially when highly sophisti
cated and expensive navigation systems are not available.
That is why we created a new frameless stereotactic system, the
Durofi frameless stereotactic system (developed by Hunan
Zhuoshichuangsi Technology Company, and approved by the
National Medical Products Administrations, China), for which a
physician only needs to read the computed tomography (CT)/
magnetic resonance imaging (MRI) film and use the laser plane to
restore the scanning state of the CT/MRI for positioning and
orientation.3
METHODS
The Durofi laser system consists of 2 parts: a laser locator and a
recording system. The laser locator is designed according to the
Cartesian coordinate system including 2 base lasers and 4 target
Key words- Frameless- Global neurosurgery- Laser- Novel stereotaxis
Abbreviations and Acronyms
CT: Computerized tomography
EAC: External auditory canals
ICH: Intracerebral hemorrhage
MRI: Magnetic Resonance Imaging
From the 1Department of Neurosurgery, The First People’s Hospital of Huaihua; Departments
of 2Neurology and 3Neurosurgery, The Second People’s Hospital of Huaihua, Huaihua,
Hunan; 4Department of Neurology, Third Xiangya Hospital, Central South University,
Changsha; 5Department of Neurosurgery, The First People’s Hospital of Zunyi, ZunYi,
Guizhou; 6Department of Neurosurgery, The Second Affiliated Hospital, Hengyang Medical
School, University of South China, Hengyang; 7Emergency Department, Xiangtan Central
Hospital, Xiangtan; and 8Department of Neurosurgery, Capital Medical University, Xuanwu
Hospital, China International Neuroscience Institute (China-INI), Beijing, China
To whom correspondence should be addressed: Lingyun Zhang, M.D.
[E-mail: 58368287@qq.com]
Supplementary digital content available online.
Citation: World Neurosurg. (2023) 174:175-182.
https://doi.org/10.1016/j.wneu.2023.03.094
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Available online: www.sciencedirect.com
1878-8750/$- see front matter ª 2023 Elsevier Inc. All rights reserved.
WORLDNEUROSURGERY174:175-182, JUNE 2023
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lasers. The base lasers are fixed on the frame to match the datum
section of CT/MRI, while the 4 target lasers are divided into
anteroposterior and lateral groups which could move to aim at the
target according to coordinates of the target point on the corre
sponding CT/MRI slice (Figure 1A). Once the target lasers are
aligned with the target, positioning is completed. At this point,
rotating 2 target lasers separately through the predetermined
surgical entry points completes orientation. The recording
system is used to record the direction indicated by the laser
locator and measure the depth of the target. It consists of 2
parts, a planner for preoperative positioning and a guider for
intraoperative guidance (Figure 1B).
Core Principles
The principle of this localization method is based on the second
axiom of solid geometry: If 2 planes have a common point, then
they have only 1 common line passing through that point. In this
device, once the anteroposterior and lateral laser axes are aimed at
the target in 1 plane, the intersection line of the 2
laser planes passes through the target point and any
entry point in space (Video 1).
Second Step
Location Phase. After the patient’s head is maintained in a neutral
position under the laser locator, the basal laser plane of the laser
locator was used to match the marked points of the datum section
on the face of the patient by adjusting the laser frame. Once the
datum section matched, we move the target laser plane to match
the patient’s target section according to the 2-plane distance be
tween the datum and target CT/MRI film. We then move ante
roposterior and lateral lasers on the external frame to aim at the
target, respectively, in the rectangular coordinates set up by the
CT/MRI.
Once the entry point on the skin has been selected, the ante
roposterior and lateral lasers are rotated to pass through the entry
point. The intersection line of the plane of the anteroposterior and
lateral laser in space is the entry trajectory. The entry trajectory is
recorded with the planner, and the target depth is measured with
the laser. The skin surface contact points of the 3 legs of the
planner and parameters such as the angular leg length of the
planner are recorded (Figure 3; Video 3).
First Step
Datum Confirmed Phase. We developed an application
for convenience that can use the CT/MRI slice dis
tance numerical value to calculate the CT/MRI scan
plane based on the relative height difference of anatomical
markers. The value of these markers, including the bilateral pu
pils/bilateral external auditory canals (EACs)/target point, were put
into the app with the result of a datum and a target section. Four
points of the chosen datum section are marked on the patient’s
face. (Figure 2; Video 2).
Video available at
www.sciencedirect.com
Operation Phase. All localization devices are main
tained with routine disinfection, and the entry tra
jector is guided by a sterilized guider that copies
coordinates of the planner. The key point to prevent
distortion is under the guidance of the adjusted
guider, and the surgical trajectory with the guidance of
the guider (Figure 4; Video 4).
Clinical Application. From August 2020 to October 2022, a total of
416 cases of new laser stereotactic surgery were carried out on
415 patients with intracranial lesions (average age 43 [range 16e
86] years, M/F ¼ 240/175) in 60 hospitals in China. Informed
consent was obtained from the patients or their families. All
patients who participated had either undergone brain CT or MRI
Figure 1. Laser locator system. (A) Laser locator: The
laser plane in the yellow circles is designed for
matching the datum section of CT/MRI scan, the laser
plane in the green circles is designed for matching
target section. (B) Planner and guider. P, the planner for
recording trajectory and measuring depth; G, the guider
for surgery guiding.
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angiography inorder toexclude thepresenceof other neuro
vascular lesions.
Therewere402casesofdeeplesions, includinglesionindeep
lobe, basal ganglia, thalamus, brainstem, and cerebellum. Su
perficial lesionswere found in 14 cases. The types of surgery
includedpunctureanddrainageof 312casesof deepbrainhe
matoma, 63 cases of brain stemhematoma, 12 cases of brain
abscess, 20casesofbrainbiopsy, 4casesof lesionlocationfor
surgicalplan,3casesofguidanceformicroscopicsurgery,and2
casesofstereotacticendoscopesurgery(Figure5).Eachkeystepof
positioningshouldbevalidated,suchaswhetherthelasersmatch
thecorrespondingCT/MRIsection,andifthe2measurementsfor
each coordinatematch eachother under the laser (Figure 6).
Because lesions were more prominent onMRI, most brain
biopsies are localizedusingMRI films.However, the accuracy
wasaffectedby the thicknessof theMRIfilm,withmost layer
differences greater than 5 mm. In order to ensure the
positioning accuracy, the diameter of the brainbiopsy lesions
weregreater than1.5cm.
Weusetheaccuracyofcatheterplacementtoevaluatetheeffect
ofsurgicalpositioningthatwasdonein405casesaccordingtothe
CT/MRIexaminationbeforeandafter theoperation.Werefer to
Figure2. Thedatumandtargetsectionandthe
application. (A)Datumandtargetsectioninthe
rectangularcoordinatesystemofCT/MRI.(B)Datumof
rightEACandthetargetsectionwhichiscalculatedand
presentedbytheappwedeveloped. (C)Fourpointsof
thechosendatumsectionaremarkedontheface.
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the MISTIE study for evaluating accuracy.4 A good catheter
position should be placed two-thirds of the way along the
longest axisof the lesionandinthemiddleof thewidthof the
lesion.Ifthecatheterwasinthelesionbutnotinthemiddletwo
thirds, itwasconsideredassuboptimal,andifthelesionwasnot
touched, itwasconsideredpoor(Figure7).
RESULTS
Satisfactory localizationwasachievedinalloperations.Nopost
operative infectionwasnoted. Inthisgroup,catheterizationwas
usedin405cases,withgoodpositionin346cases (85.4%) and
suboptimal position in 59 cases (14.6%). There were 5 post
operative rebleeding cases after surgery. Four of themwere
intracerebral hemorrhage patients with poor blood pressure
management, and 1 biopsy casewith abundant blood supply
lesion.
Thedurationof locatingfromtheplacementof thelaserframe
tothecompletionof thepositioningwasrecordedaccordingto3
positionsofthepatients.Themeantimespent in3positionswas
as follows: 11minutes insupineposition, 16minutes in lateral
position,and21minutesinproneposition(Figure8).
DISCUSSION
Precisepositioningis thefoundationofneurosurgery.Tomogra
phy imagingtechnology, representedbyCTandMRI,hasmade
micro lesions “visible”. Both frame and frameless stereotactic
devicessharethesimilartechnical ideaofformingimage-spacein
acomputerbasedonhigh-qualityDICOMdataofCTscansub
sequentlyas tocomplete thepositioningandorientationof any
intracranial target and thenmatch thephysical spacewith the
image-space through the framefixedonskull (frame) or space
camera(frameless).5
High-quality scan datameans close coordination with the
radiologydepartment,whichisnoteasyforemergencysurgeryat
night.Arelativelycomplexcombinationofsoftwareandhardware
andhumanecomputer interactionmeans ahigh learningcurve
Figure3. Theprocessof laserstereotaxissystem. (A)
Thelasersmatchthedatumandthetargetsectionof
CT/MRI. (B)Therotationaxisofanteroposteriorand
lateral lasersareaimedatthetarget. (C)Target
orientation,theintersectionlineofthe2laserplanesat
thepuncturepointwasthetrajectory(bluearrow). (D)
Theplanner recordsthetrajectoryandmeasuresthe
depthincombinationwiththelaser.
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andlessskillfulusers.Thismayexplainpartof thephenomenon
that, even thoughbeingavailable fordecades, these frameand
frameless stereotacticdevices are far fromubiquitous inglobal
neurosurgery.6
Globalneurosurgeryistheclinicalandpublicheathpracticeof
neurosurgerywiththeprimarypurposeof ensuringtimely, safe,
andaffordableneurosurgerycaretoallwhoneedit.7,8However,
the lack of widespread application of precise positioning
technology severely hinders the progress of global
neurosurgery.9-11 As demonstratedby the 44 essential surgical
procedures in theDisease Control Priorities published by the
WorldBank,burrholedrainageof intracranialhematoma is the
onlyneurosurgicalprocedure.12Thecost-effectiveimprovementof
surgical precision will undoubtedly expand the usability of
neurosurgery. Therefore, there is anurgent need todevelopa
simple,rapid,andaccuratestandardizedlocalizationdevicemore
readablyadoptablefor theglobalpopulation.13
ThebiggestadvantageoftheDurofilaserpositioningsystemis
that ituseslaser todirectlymaptheCartesiancoordinatesystem
containedintheCT/MRIfilmtothepatient’sheadfordirectand
rapidpositioningandorientation.The initialCT/MRI scanof a
patient has already establisheda standardCartesiancoordinate
systemfor theirhead.Bymatching theCTscansectionwitha
laserplaneoutsidethebody,anytargetintheheadcanbelocated
laterallyandanteriorly.Thereafter,directionfromanypointonthe
non-targetplanetothetargetcanbedeterminedbyrotatingthe
lateralandanterior laserbaseontheplaneintersectionprinciple.
Themethoddescribedhere differs fromcurrent stereotactic
frames inseveral ways. For example, it is frameless, doesnot
requirepatientstobetransferredfor imagingprior totheopera
tion,anddoesnot requiredisinfectionof theframebeforeoper
ation.Theuseofbasic3-dimensionalgeometrictools insteadof
complex computer analysis andexpensiveequipment platforms
simplifies localizationof intracranial targets in a cost-effective
manner that is easily taught and readily available in resource
limitedenvironments.
Theerrorinsurgicalpositioningaccuracymainlycomesfrom3
places:mechanical error, registrationerror, andoperationerror.
Inthis study,mechanical errordependson theaccuracyof the
positioner laser,which is less than0.5mm, and thedegreeof
Figure4. Theprocessofguiderguidedoperation. (A)
Parametersoftheplannerarerecordedandmarkedon
thescalp. (B)Theguider replicatestheplannerand
guidesthesurgical trajectory.
Figure5. Operationtypes.
WORLDNEUROSURGERY174:175-182,JUNE2023 www.journals.elsevier.com/world-neurosurgery 179
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matchingbetweentheguiderandthedrainagetube.Adrainage
tubewithahighdegreeofmatchingandgooddirectivityshould
beselected.
Registrationerrorsmainly arise fromtheaccuracyof regis
trationpointsandtargetpointcoordinates.Althoughchoosing
theEACandeyeballastheregistrationpoints isconvenient for
clinicaluse,itcancausecertainerrors.ThethicknessofCT/MRI
scanningandtargetcoordinatemeasurementcanalsoaffect the
accuracy.
Operationerrormainlyarisesfromthemovementoftheguider
on the scalp andwhether the puncture path remains unob
structed.Werecommendthispositioningsystemfor locatingle
sionswithadiametergreaterthan1.5cm,especiallylesionsinthe
basalgangliaareathatareclosetothecenterof thehead.
Because this is a retrospective study, therewas no control
group. Further improvements and research are essential for
widespreadimplementation.
CONCLUSIONS
Thenewlaser stereotaxis systemdescribed in this article sim
plifies thepositioningprocessby selecting theorientationand
appropriate depth through a CT/MRI coordinate system laser
plane.Thisnewstereotactic technique isconducive totherapid
popularizationofprecisionneurosurgery,andisworthyoffurther
research.
CRediTAUTHORSHIPCONTRIBUTIONSTATEMENT
DanTang: Investigation, Resources, Methodology,Writinge
original draft. Jun liu: Writing e original draft, Validation.
ChunwenXiao:Writingereview&editing, Supervision.Dujie
Xie: Writinge review& editing, Supervision. Xiaohong Fu:
Figure6. Theprocessof intracerebralhemorrhagepuncture. (A)Lasersin
framematchesthedatumandthetargetsection.(B)Axisoflasersaimedat
thetarget. (C)Plannerrecordsthetrajectory. (D)Depthismeasured. (E)
Guiderguidesthesurgery.(F)Drainagetubefixedintoanappropriatelength
afterasmallamountofhematomaisremoved.
Figure7. Catheterplacement isgradedasgood(346
cases,85.4%),suboptimal (59cases,14.6%),orpoor
(0cases).
180 www.SCIENCEDIRECT.com WORLDNEUROSURGERY,https://doi.org/10.1016/j.wneu.2023.03.094
DOINGMOREWITHLESS
DANTANGETAL. NOVELFRAMELESSLASERSTEREOTAXISSYSTEM
Writingereview&editing,Supervision.ShenghuaCui:Writing
ereview&editing, Supervision. BoHe:Writingereview&
editing, Supervision.MingchuLi:Writingereview&editing,
Supervision. Lingyun Zhang: Conceptualization, Investigation,
Projectadministration,Validation,Visualization,Writingeorig
inaldraft.
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WORLDNEUROSURGERY174:175-182,JUNE2023 www.journals.elsevier.com/world-neurosurgery 181
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commercial or financial relationships that could be construed
as a potential conflict of interest.
13. Yang Z, Hong B, Jia Z, et al. Treatment of supra
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
Received 1 March 2023; accepted 22 March 2023
Citation: World Neurosurg. (2023) 174:175-182.
https://doi.org/10.1016/j.wneu.2023.03.094
Journal homepage: www.journals.elsevier.com/world
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$- see front matter ª 2023 Elsevier Inc. All
rights reserved.
182 www.SCIENCEDIRECT.com
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